CONTRACT
BETWEEN (PRIMARY CONTRACTOR NAME)
AND
[SUBCONTRACTOR NAME]
This Contract, by and between [PRIVATE PROVIDER NAME] herein referred to as the “Contractor” and
[SUBCONTRACTOR LEGAL ENTITY N AME], hereinafter referred to as the “Subcontractor” is for the
provision of [NUMBER OF SLOTS/BEDS] [SHORT DESCRIPTION OF THE SER VICE], as further defined in
the "SCOPE OF SERVICES”.
The Subc ontractor’s address is:
[ADDRESS]
The location(s) of the service provision are:
[ADDRESS OF EACH LOCA TION WHE RE CHILD WILL RE CE IVE SERVICE(S)}
A. SCOPE OF SER VICES:
A.1. These Subcontracted Services are provided under the Contractor’s State Contract
[NUMBE R(S)] for the following service(s): [SERVICES }
A.2. [DESCRIBE IN DETAIL THE SER VICES THE SUBCONTRACTOR IS TO PROVIDE ON BEHALF
OF THE STATE]
B. CONTRACT TER M:
B.1. Subcontract Term. This Subcontract shall be effective for the period commencing on [START
DATE] and ending on [END DATE]. The Contractor shall have no obligation for services rendered
by the Subcontractor, which are not performed within the specified period.
C. PAYMENT TERMS AND CONDITIONS:
C.1. Liability. The Contractor shall bear full responsibility for compensation to the Subcontractor under
the terms of this contract. In no event shall the State of Tennessee bear responsibility for
compensation to the Subcontractor under this contract.
D. STAND ARD TERMS AND CONDITIONS:
D.1. Required Approvals . No services on behalf of the State of Tennessee, Department of Children’s
Services (DCS), may be provided under this contract until the Contractor receives written approval
from the Contract and Grants Management Unit of DCS
D.2. Modification and Amendment. This Contract may be modified only by a written amendment
executed by all parties hereto and approved, in writing, by the appropriate Tennessee State
officials in accordance with applicable Tennessee State laws and regulations.
D.3. Subcontracting. The Subcontractor shall not assign this Contract or enter into a subcontract for
any of the services performed under this Contract.
D.4. Conflicts of Interest. The Subcontractor warrants that no part of the total Contract Amount shall be
paid directly or indirectly to an employee or official of the State of Tennessee as wages,
compensation, or gifts in exchange for acting as an officer, agent, employee, or consultant to the
Subcontractor in connection with any work contemplated or performed relative to this Contract.
D.5. Nondiscrimination. The Subcontractor hereby agrees, warrants, and assures that no person shall
be excluded from participation in, be denied benefits of, or be otherwise subjected to discrimination
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in the performance of this Contract or in the employment practices of the Subcontractor on the
grounds of disability, age, race, color, religion, sex, national origin, or any other classification
protected by Federal, Tennessee State constitutional, or statutory law. The Subcontractor shall,
upon request, show proof of such nondiscrimination and shall post in conspicuous places, available
to all employees and applicants, notices of nondiscrimination.
D.6. Records. The Subcontractor shall maintain documentation for all charges under this Contract. The
books, records, and documents of the Subcontractor, insofar as they relate to work performed or
money received under this contract, shall be maintained for a period of three (3) full years from the
date of the final payment and shall be subject to audit at any reasonable time and upon reasonable
notice by the State, the Comptroller of the Treasury, or their duly ap pointed representatives. The
financial statements shall be prepared in accordance with generally accepted accounting principles.
D.7. Monitoring. The Subcontractor’s activities conducted and records maintained pursuant to this
Contract shall be subject to monitoring and evaluation by the State, the Comptroller of the
Treasury, or their duly appointed representatives.
D.8. Independent Contractor. The parties hereto, in the performance of this Contract, shall not act as
employees, partners, joint venturers , or associates of one another. It is expressly acknowledged by
the parties hereto that such parties are independent contracting entities and that nothing in this
Contract shall be construed to create an employer/employee relationship or to allow either to
exercise control or direction over the manner or method by which the other transacts its business
affairs or provides its usual services. The employees or agents of one party shall not be deemed or
construed to be the employees or agents of the other party for an y purpose whatsoever.
The Subcontractor, being an independent contractor and not an employee of the State, agrees to
carry adequate public liability and other appropriate forms of insurance, including adequate public
liability and other appropriate forms of insurance on the Contractor’s employees, and to pay all
applicable taxes incident to this Contract.
D.9. State and Federal Compliance. The Subcontractor shall comply with all applicable State
and Federal laws and regulations in the performance of this Contract.
D.10. Prohibition of Illegal Immigrants. The requirements of Public Acts of 2006, Chapter
Number 878, of the state of Tennessee, addressing the use of illegal immigrants in the
performance of any Contract to supply goods or services to the state of Tennessee, shall
be a material provision of this Contract, a breach of which shall be grounds for monetary
and ot her penalties, up to and including termination of this Contract.
a. The Contractor hereby attests, certifies, warrants, and assures that the
Cont ractor shall not knowingly utilize the services of an illegal immigrant in the
performance of this Cont ract and shall not knowingly utilize the services of any
subcontractor who will utilize the services of an illegal immigrant in the
performance of this Cont ract. The Contractor shall reaffirm this attestation, in
writing, by submitting to the State a completed and signed copy of the document
at Attachment A, hereto, semi-annually during the period of this Contract. Such
attestations shall be maintained by the Contractor and made available to state
officials upon request.
b. Prior to the use of any subcontractor in the performance of this Cont ract, and
semi-annually thereafter, during the period of this Contract, the Contractor shall
obtain and retain a current, written attestation that the subcontractor shall not
knowingly utilize the services of an illegal immigrant to perform work relative to
this Contract and shall not knowingly utilize the servic es of any subcontractor
who will utilize the services of an illegal immigrant to perform work relative to this
Cont ract. Attestations obtained from such subcontractors shall be maintained by
the Contractor and made available to state officials upon request.
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c. The Contractor shall maintain records for all personnel used in the performance
of this Contract. Said records shall be subject to review and random ins pection
at any reasonable time upon reasonable notice by the State.
d. The Contractor understands and agrees that failure to comply with this section
will be subject to the sanctions of Public Chapter 878 of 2006 for acts or
omissions occurring after its effective date. This law requires the Commissioner
of Finance and Administration to prohibit a contractor from contracting with, or
submitting an offer, proposal, or bid to contract with the State of Tennessee to
supply goods or services for a period of one year after a contractor is discovered
to have knowingly used the services of illegal immigrants during the performance
of this Contract.
e. For purposes of this Contract, "illegal immigrant" shall be defined as any pers on
who is not either a United States citizen, a Lawful Permanent Resident, or a
person whose physical presenc e in the United States is authorized or allowed by
the federal Department of Homeland Security and who, under federal
immigration laws and/or regulations, is authorized to be employed in the U.S. or
is otherwise authorized to provide services under the Contract.
E. SPECIAL TER MS AND CONDITIONS:
E.1. Confidentiality of Records. Strict standards of confidentiality of records and information shall be
maintained in accordance with applicable state and federal law. All material and information,
regardless of form, medium or method of communication, provided to the Subcontractor by the
Contractor or acquired by the Subcontractor on behalf of the Contractor shall be regarded as
confidential information in accordance with the provisions of applicable state and federal law, state
and federal rules and regulations, departmental policy, and ethical standards. Such confidential
information shall not be disclosed, and all necessary steps shall be taken by the Subcontractor to
safeguard the confidentiality of such material or information in conformance with applicable state
and federal law, state and federal rules and regulations, departmental policy, and ethical standards.
The Subcontractor’s obligations under this section do not apply to information in the public domain;
entering the public domain but not from a breach by the Subcontractor of this Contract; previously
possessed by the Subcontractor without written obligations to the Contractor to protect it; acquired
by the Subcontractor without written restrictions against disclosure from a third party which, to the
Subcontractor’s knowledge, is free to disclose the information; independently developed by the
Subcontractor without the use of the Contractor information; or, disclosed by the Contractor to
others without restrictions against disclosure. Nothing in this paragraph shall permit Subcontractor
to disclose any information that is confidential under federal or state law or regulations, regardless
of whether it has been disclosed or made available to the Subcontractor due to intentional or
negligent actions or inactions of agents of the Contractor or third parties.
It is expressly understood and agreed the obligations set forth in this section shall survive the
termination of this Contract.
E.2. HIPAA Compliance. Subcontractor warrants to the Contractor that it is familiar with the
requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its
accompanying regulations, and will comply with all applicable HIPAA requirements in the course of
this contract. Subcontractor warrants that it will cooperate with the Contractor in the course of
performance of the contract so that both parties will be in compliance with HIPAA, including
cooperation and coordination with State privacy officials and other compliance officers required by
HIPAA and its regulations. Subcontractor will sign any documents that are reasonably necessary to
keep the Contractor and Subcontractor in compliance with HIPAA, including but not limited to
business associate agreements.
E.3. Environmental Tobacco Smoke. Pursuant to the provisions of the federal “Pro-Children Act of
1994” and the Tennessee “Children’s Act for Clean Indoor Air of 1995,” the Subcontractor shall
prohibit smoking of tobacco products within any indoor premises in which services are provided to
individuals under the age of eighteen (18) years. The Subcontractor shall post “no smoking” signs
in appropriate, permanent sites within such premises. This prohibition shall be applicable during all
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hours, not just the hours in which children are present. Violators o f the prohibition may be subject
to civil penalties and fines.
E.4. Incorporation of additional Documents. Attached to this sub-contract are the following documents:
a. A cop y of all appropriate valid license (Subcontractor);
b. Monitoring Plan;
c. Organizational chart and Overview of Subcontractor(s) program(s);
d. Training Plan and/or Schedule of training;
e. Education approval letters from DOE and DCS (when applicable)
f. Conflict of Interest statements signed by agency Board of Directors
E.5. Lobbying. The Subcontractor certifies, to the best of its knowledge and belief, that:
No federally appropriated funds have been paid or will be paid, by or on behalf of the
Subcontractor, to any person for influencing or attempting to influence an officer or employee of
any agency, a Member of Congress in connection with the awarding of any federal contract, the
making of any federal grant, the making of any federal loan, and entering into any cooperative
agreement, and the extension, continuation, renewal, amendment, or modification of any federal
contract, grant, loan, or cooperative agreement.
If any funds other than federally appropriated funds have been paid or will be paid to any person for
influencing or attempting to influence an officer or employee of any age ncy, a Member of Congress,
an officer or employee of Congress, or an employee of a Member of Congress in connection with
this contract, grant, loan, or cooperative agreement, the Subcontractor shall complete and submit
Standard Form-LLL, “Disclosure Form to Report Lobbying,” in accordance with its instructions.
E.6. Public Accountability. If this Contract involves the provision of services to citizens by the
Subcontractor on behalf of the State, the parties agree to establish a system through
which recipients of services may present grievances about the operation of the service
program.
E.7. Hold Harmless. The Subcontractor agrees to indemnify and hold harmless the State of Tennessee
as well as its officers, agents, and employees from and against any and all claims, liabilities,
losses, and causes of action which may arise, accrue, or result to any person, firm, corporation, or
other entity which may be injured or damaged as a result of acts, omissions, or negligence on the
part of the Subcontractor, its employees, or any person acting for or on its or their behalf relating to
this Contract.
In the event of an y such suit or claim, the Subcontractor shall give the State immediate notice
thereof and shall provide all assistance required by the State in the State’s defense. The State
shall give the Subcontractor written notice of any such claim or suit, and the Subcontractor shall
have full right and obligation to conduct the Subcontractor’s own defense thereof. Nothing
contained herein shall be deemed to accord to the Subcontractor, through its attorney(s), the right
to represent the State of Tennessee in any legal matter, such rights being governed by Tennessee
Code Annotated, Section 8-6-106.
E.8. DCS Ownership of Case Files . The Department of Children’s Services shall have all ownership
right, title, and interest, in all case files created, designed, developed, derived, documented,
installed, or maintained on behalf of DCS under this Contract. DCS shall have unlimited rights to all
said case files. The Subcontractor shall furnish such information and data upon request of the
DCS, in accordance with the Contract and applicable State law.
E.9. Requirements Bureau of TennCare. The Private Provider must comply with the following
requirements as stipulated in the Contract bet ween The Department of Children’s
Services and the Department of Finance and Administration, Bureau of TennCare.
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A. The Private Provider must disclose the following information in accordance with
the Code of Federal Regulations, Title 42, Part 455, Subpart B:
(1) The name and address of each person wit h an ownership or cont rol
interest in the disclosing entity or in any subcontractor in which the
disclosing entity has direct or indirect ownership of 5 perc ent or more;
(2) Whether any of the persons named, in compliance with paragraph
E.24.A(1) of his section, is related to another as spouse, parent, child, or
sibling;
(3) The name of any other disclosing entity in which a person with an
ownership or control interest in the disclosing entity also has an
ownership or control interest. This requirement applies to the extent that
the disclosing entity can obtain this information by requesting it in writing
from the person. The disclosing entity must—
(a) Keep copies of all these requests and the responses to them;
(b) Make them available to the Sec retary or TennCare upon request;
and
(c) Advise the TennCare when there is no res ponse to a request.
B. The Private Provider must furnish to TennCare or to the Sec retary on request ,
information related to business transactions in accordance with paragraph (1) of this
section.
(1) The Private Provider must submit, within 35 days of the date on a
request by the Secretary or TennCare, full and complete information
about:
(a) The ownership of any subcontractor with whom the Private
Provider has had business transactions totaling more than
$25,000 during the 12-month period ending on the date of the
request; and
(b) Any significant business transactions between the Privat e
Provider and any wholly owned supplier, or between the Private
Provider and any subcontractor, during the 5 -year period ending
on the date of the request.
C. Before DCS enters into or renews a contract, or at any time upon written request by
TennCare, the Private P rovider must disclose to DCS and the Medicaid Agency the
identity of any person who:
(1) Has ownership or control interest in the Privat e Provider, or is an agent
or managing employee of the Private Provider; and
(2) Has been convicted of a criminal offense related to that person's
involvement in any program under Medicare, Medicaid, or the title XX
services program since the inc eption of those programs.
TennCare must notify the Inspector General of the Department of any disclosures made
under paragraph E.24.C. of this section within 20 working days from the date it receives
the information. The Private Provider must also promptly notify the Inspector General of
the Department of any action it takes on the provider's application for participation in the
program.
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D. DCS or TennCare may refuse to enter int o or renew a contract with a Private Provider if
any pers on who has an ownership or control interest in the Private Provider, or who is an
agent or managing employee of the Private Provider, h as been convicted of a criminal
offense related to that person's involvement in any program established under Medicare,
Medicaid or the title XX Services Program.
E. DCS or TennCare may refuse to enter int o or may terminate a Private Provider contract if
it determines that the Private Provider did not fully and accurately make any disclosure
required under paragraph C.of this section.
F. Provider Requirements: Participation in the TennCare program will be limited to Private
Providers who:
1. Agree that the provider may not refuse to provide covered medically
necessary or covered preventive services to a child under the age of
twenty-one (21) or a TennCare Medicaid patient under this Cont ract for
non-medical reasons. However, the provider shall not be required to
accept or continue treatment of a patient with whom the provider feels
he/she cannot establish and/or maintain a professional relationship;
2. Agree that emergency services be rendered without the requirement
of prior authorization of any kind;
3. Maintain an adequate record system and agree that all records be
maintained for five (5) years from the close of the contract or retained
until all evaluations, audits, reviews or investigations or prosecutions
are completed for recording enrollee services, servicing providers,
charges, dates and all other commonly accept ed information elements
for servic es rendered to enrollees pursuant to the contract (including
but not limited to such records as are necessa ry for the evaluation of
the quality, appropriateness, and timeliness of services performed
under the provider cont ract and administrative, civil or criminal inve
stigations and prosecutions).
4. Acknowledge and understand that as a condition of participation in
TennCare, enrollees give the TennCare Bureau, the Tennessee
Comptroller of the Tennessee Bureau of Investigation Medicaid Fraud
Cont rol Unit (TBI MFCU), Unit ed States Department of Health and
Human Services (DHHS) the DHHS Offic e of Inspector General (DHHS
OIG), and the United States Department of Justice (DOJ), and any
other authorized state or federal agency, access to their records. Said
records shall be made available and furnished immediately upon request
for fiscal audit, medical audit, medical review, utilization review, and
other periodic monit oring as well as for administrative, civil and criminal
investigations or prosec utions upon the request of an aut horiz ed
representative of the Private Provider, TennCare or authorized federal
and state personnel, including, but not limited to, the Tennessee (TN
OIG), the Tennessee Department of Children’s Services Office of
Inspector General (TDCS OIG), the TB I MFCU, the DHHS OIG and the
DOJ.
5. Agree that medical records requirements medic al records be
maintained at site where medical services are rendered and that
enrollees aged 14 and over and enrollee authorized representatives shall
be given access to the enrollees' medical records, to the extent and in
the manner provided by T.C.A. Sections 63-2-101 and 63-2-102, and,
subject to reasonable charges, be given copies thereof upon request.
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6. Agree that TennCare , DHHS, and the DHHS OIG, the Tennessee
Comptroller of the Treasury, TN OIG, TB I MFCU, and DOJ, as well as
any other authorized state or federal agency or entity shall have the right
to evaluate through inspection, evaluation, review or request, whether
announced or unannounced, or other means any records pertinent to t his
Cont ract including, but not limited to medical records, billing records,
financial records, and/or any records related to services rendered,
quality, appropriateness and timeliness of services and/or any records
relevant to an administrative, civil and/ or criminal investigation and/ or
prosecution and such evaluation, inspection, review or request, and
when performed or requested, shall be performed with the immediate
cooperation of the provider. Upon request, the Private Provider shall
assist in such reviews including the provision of complete copies of
medical records. Include a statement that HIPAA does not bar disclosure
of Protected Health Information (PHI) to TennCare, TN OIG, TB I MFCU,
DHHS, DHHS OIG and DOJ when and as aut horized by HIPAA. Provide
that any authorized state or federal agency or entity, including, but not
limited to TennCare, TN OIG, TBI MFCU, DHHS, DHHS OIG, DOJ,
the Tennessee Comptroller of the Treasury, may use these records and
information for administrative, civil or criminal investigations and
prosecutions;
7. Accept monitoring, whether announced or unannounced, of servic es
rendered to enrollees sponsored by the Private Provider; 8. Whether
announced or unannounced, participate and cooperate in any internal
and external Quality Management/Quality Improvement, utilization
review, peer review and appeal procedures established by DCS and/or
TennCare ;
8. Initiate corrective action where necessary to improve quality of care, in
accordance with that level of medical care which is recognized as
acceptable professional practice in the res pective community in whic h
the Private Provider practices and/or the standards established by
TennCare;
9.Provide for submission of all reports and clinical information required
by DCS;
10.Cooperate with all appropriat e State and Federal Agencies, including
TB I MFCU and/or TN OIG, in investigating fraud and abuse. In addition,
the Private P rovider shall fully comply with the provisions of Tennessee
Code Annotated Sections 71-5-2601 and 71-5-2603 in performance of
its' obligations under this Contract.
(a) Fraud and abuse in the administration of the program. Suspected
fraud and abuse in the administration of the program shall be reported to
TB I MFCU and/or TN OIG.
(b) Provider fraud and abuse. All confirmed or suspected provider fraud
and abuse shall immediately be reported to TB I MFCU.
(c) Enrollee fraud and abuse. All confirmed or suspected enrollee fraud
or abuse shall be report ed immediately to TN OIG.
11.Upon request and as required by this Contract or state and/or federal
law, make available to the TB I MFCU/ TN OIG any and all administrative,
financial and medical records relating to the delivery of items or services
for which TennCare monies are expended. In addition, the TB I
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MFCU/TN OIG shall, as required by this Contract or state and/or federal
law, be allowed access to the place of business and to all TennCare
records of the Private Provider, during normal business hours, except
under special circumstances when after hour admission shall be allowed.
Special circumstances shall be determined by the TBI MFCU/TN OIG.
12.Secure all necessary liability and malpractice insuranc e coverage as
is necessary to adequately protect the enrollees and DCS under this
Cont ract. The Private Provider shall provide such insurance coverage at
all times during the Contract and upon execution of the Private Provider
Cont ract furnish DCS with written verification of the existence of such
coverage;
13.Agree to recogniz e and abide by all state and federal laws,
regulations and guidelines applicable to the health plan.
14. Acknowledge that this Private Provider Contract incorporates by
reference all applicable federal and state laws, TennCare rules and
regulations or court orders, and revisions of such laws or regulations
shall automatically be incorporated int o the Contract, as they become
effective. In the event that changes in the Contract as a result of
revisions and applicable federal or state law materially affect the position
of either party, DCS and Private Provider agree to negotiate such further
amendments as may be necessary to correct any inequities;
15.Recognize that in the event of termination of the Contract bet ween
DCS and TennCare for any of the reasons, the Private Provider shall
immediat ely make available, to TennCare, or its designated
representative, in a usable form, any or all records, whet her medical or
financial, related to the Private Provider's activities undertaken pursuant
to the DCS/Private P rovider Contract. The provision of such records
shall be at no ex pense to TennCare;
16.Warrant that no part of the total Cont ract amount provided herein
shall be paid directly, indirectly or through a parent organization,
subsidiary or an affiliate organization to any state or federal officer or
employee of the State of Tennessee or any immediate family member of
a state or federal officer or employee of the State of Tennessee as
wages, compens ation, or gifts in exchange for acting as officer, agent,
employee, subcontractor, or consultant to the Private Provider in
connection with any work contemplated or performed relative to this
Cont ract unless disclosed to the Commissioner, Tennessee Department
of Finance and Administration. For purpos es of Section E.24. f.17 and its
subparts of thisContract, “immediate family member” shall mean a
spouse or minor child(ren) living in the household.
Quarterly, by January 30, April 30, July 30, and October 30 each year, or at other times or
intervals as designated by the Deputy Commissioner of the B ureau of TennCare and
communicated, in writing, to the Private Provider by DCS, disclosure shall be made by the Private
Provider to DCS in writing and DCS will forward the disclosure to the Deputy Commissioner of the
Bureau of TennCare, Department of Finance and Administration. The disclosure shall include, but
not be limited to, the following:
(a) A list of any state or federal officer or employee of the State of
Tennessee as well as any immediate family member of a state or federal
officer or employee of the State of Tennessee who receives wages or
compens ation from the Privat e Provider; and
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(b) A statement of the reason or purpose for the wages or compens ation.
The disclosures shall be made by the Private Provider and reviewed by TennCare in accordance
with Standard Operating Procedures and the disclosures shall be distributed to, amongst other
persons, entities and organizations, the Commissioner, Tennessee Department of Finance and
Administration, the Tennessee Ethics Commission, the TennCare Oversight Committee and the
Fiscal Review Committee.
This Cont ract may be terminated by DCS and/or the Private Provider may be subject to
sanctions under this Contract if it is determined that the Private Provider, its agents or employees
offered or gave gratuities of any kind to any state or federal officials or employees of the State of
Tennessee or any immediate family member of a state or federal officer or employ ee of the State
of Tennessee if the offering or giving of said gratuity is in contravention or violation of state or
federal law. It is understood by and bet ween the parties that the failure to disclose information as
required under Section E.24. f.17 of this Contract may result in termination of this Contract and
the Private Provider may be subject to sanctions in accordance with the provisions of this
Cont ract. The Private Provider certifies that no member of or delegat e of Congress, the United
States General Accounting Office, DHHS, Centers for Medicare and Medic aid Services (CMS),
or any other federal agency has or will benefit financially or materially from this Contract.
17.Certify by signing this Contract, to the best of its knowledge and
belief, that federal funds have not been used for lobbying in accordance
with 45 CFR Part 93 and 31 USC 1352. (See also TCA 3 -6-101 et seq.,
3-6-201 et seq., 3-6-301 et seq ., and 8-50-505. ).
18. Assure that all material and information, in particular information
relating to enrollees or potential enrollees, which is provided to or
obtained by or through Private P rovider’s performance under this
Cont ract, whether verbal, written, tape, or otherwise, shall be reported as
confidential information to the extent confidential treatment is provided
under state and federal laws. The Private Provider shall not use any
information so obtained in any manner except as necessary for the
proper discharge of its obligations and securement of its rights under this
Cont ract.
All information as to personal facts and circumstances concerning enrollees or potential enrollees
obtained by the Private Provider shall be treated as privileged communications, shall be held
confidential, and shall not be divulged without the written consent of DCS or TennCare or the
enrollee/ potential enrollee, provided that nothing stated herein shall prohibit the disclosure of
information in summary, statistical, or other form which does not identify particular individuals.
The use or disclosure of information concerning enrollees/pot ential enrollees shall be limited to
purposes directly connected wit h the administration of this Contract.
19.Accept general and targeted education regarding emergency appeals,
including when an emergency appeal is appropri ate, and proc edures for
providing written certification thereof, and comply with the appeal
process, including but not limited to, assisting an enrollee by providing
appeal forms and contact information including the appropriate address
for submitting appeals for state level review; and
20.Display notices of the enrollee’s right to appeal advers e action
affecting services in public areas of their facility(s) in accordance with
TennCare rules and regulations, subsequent amendments, or any and all
court orders. DCS shall ens ure that Privat e Providers have correct and
adequate supply of public notices;
21.Acknowledge that the Private Provider has been informed of the
package of benefits that Early and Periodic Screening, Diagnosis and
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Treatment (EPSDT TE NNderCare) offers as set out in Section 2 -3.u of
the TennCare MCO Contractor Risk Agreement (CRA ) and whic h
requires providers to make treatment decisions based upon children’s
individual medical and behavioral healt h needs. The Private Provider
further acknowledges that a copy of Section 2-3.u can be accessed on
the TennCare web site will be furnished to the provider upon request.
The TennCare Web site is found at:
hhttp://www.state.tn.us/tenncare/healthplans/TCMCO1.htm
22. Agree not to enc ourage or suggest, in writing or verbally, that
TennCare children be placed int o state custody in order to receive
medical or behavioral services covered by TennCare;
23.Agree to follow DCS and TennCare procedures for the provision of
language interpretation and translation services for any enrollee who
needs such services, including but not limited to, enrollees with Limited
English Proficiency.
24.Agree that if any requirement in the Private Provider Contract is
determined by TennCare to conflict with the Contract between
TE NNCARE and DCS, such requirement shall be null and void
E. 11. Supplemental Conflict of Interest. The Contractor shall not have any owner, member of the
board of directors, or member of the board of trustees of that Contract Contractor who
also holds any other position which may influence the placements provided to children in
the plaintiff class of Brian A. v. Phil Bredesen. Such positions include, but are not limited
to juvenile court judges, referees or ot her court officers involved in the individual cases of
children in foster care. This document is incorporated into your contract as Attachment
B. and all ot her provisions shall remain in full force and effect
Certify by signing this Contract that the Private Provider has not been excluded from
participation in the Medicare and/or Medicaid programs purs uant to Sections 1128 or 1156 of
the Social Security Act or who are otherwise not in good s tanding with the TennCare
program.
IN WITNESS WHEREOF:
[SUBCONTRACTOR LEGAL ENTITY NAME]:
[NAME AND TITLE] Date
[PRIVATE PROVIDER LEGAL ENTITY NAME]:
[NAME AND TITLE] Date
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ATTACHMENT A
ATTEST AT ION RE PERS ONNEL USED IN CONTR AC T
PERFORM ANCE
SUBJ ECT CONTRACT NUMBER:
CONTRACTOR LEGAL ENTITY NAME:
FEDERAL EMPLOYER IDENTIFICATION
NUMBER:
(or Social Security Number)
The Contractor, identified above, does hereby attest, certify, warrant, and
assure that the Contractor shall not knowingly utilize the services of an
illegal immigrant in the performance of this Contract and shall not
knowingly utilize the services of any subcontractor who will utilize the
services of an illegal immigrant in the performance of this Contract.
CONTRACTOR SIGNATURE
NOTICE: This attestation MUST be signed by an individual empow ered to contractually bind the Contractor. If said
individual is not the chief executiv e or president, this document shall attach evidence showing the indiv idual’s authority to
contractually bind the Contractor.
PRINTED NAME AND TITLE OF SIGNATORY
DATE OF ATTESTATION
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CONFLICT OF INTEREST STATEMENT
Pursuant to provider’s contract section E.11 the following applies:
E. 11. Supplemental Conflict of Interest. The Contractor shall not have any owner, member of the board of directors, or
member of the board of trustees of that Contract Contractor who also holds any other position which may influence t he
placements provided to children in the plaintiff class of Brian A. v. Phil Bredesen. Such positions include, but are not
limited to juvenile court judges, referees or other court officers involved in the individual cases of children in foster car e.
This document is incorporated into your contract as Attachment I.
Agency Name:
Address:
State of Incorporation: Federal ID/Vend #:
Name of Chief Executive Officer:
Name of Board Member Employer: Name of Board Member: Employer:
Signature of CEO/Executive Director: ___________________________________ Date:
13 Updated 6/10/2010
Each owner, member of the board of directors, or member of the board of trustees of the
agency must complete and sign this document.
Name of Agency:
Name of Board Member:
Title: Occupation:
Business Address:
Phone Number:
I understand that DCS is prohibited from contracting with any agency for which any owner, member of the
board of directors, or member of the board of trustees of that agency also holds any position which may
influence the placements provided to children who are adjudicated dependent and neglected or unruly. I
understand that such positions include, but are not limited to, juvenile court judges, referees or other court
officers involved in the individual cases of children in foster care.
I certify that I do not hold a judicial or non-judicial position (with a juvenile court or other court) involved in
individual cases of children in foster care.
I further certify that I do not hold any other position which may influence the placements provided to children
adjudicated dependent and neglected or unruly.
I understand that if I have any question about whether a position that I hold is one that would make my agency
ineligible to contract with DCS, I should obtain clarification from the DCS Child Placement & Private Providers
Unit of the Department of Children's Services before signing this statement.
Name of Member:
Signature of Member: __________________________________ Date:
1